THE UNIVERSITY OF MISSISSIPPI

THE UNIVERSITY OF MISSISSIPPI Appeal for Exception to Tuition Refund Policy

This space is for Refund Committee use only.

INSTRUCTIONS: Complete form, attach any appropriate documentation and send to: Refund Committee

APPEAL NUMBER____________

Office of the Bursar

P.O. Box 1848

University, MS 38677

Please print or use computer to complete this form

Fax: 662-915-5097

________________________________________________________________________ (NAME: Last ? First ? MI)

____________________________ (Student ID Number)

___________________________________________________________________________________________________________ (Address ? for mailing notification of Committee's decision)

___________________________________________________________________________________________________________

(City)

(State)

(Zip Code)

__________________________________________________ (Email address )

____________________________________________ Phone Number (daytime)

TERM (Circle only one): FALL

SPRING

Intersession

May / August / Winter

Summer

Full 1ST Term

2ND TERM

YEAR: ___________

PLEASE ANSWER THE FOLLOWING QUESTIONS BY CIRCLING "YES" OR "NO":

Did you attend any classes during the term covered by this appeal? If no, request each instructor

to confirm this fact by emailing to the following address: mailto:bursar@olemiss.edu .

Please explain below why you did not attend any classes.

YES

NO

Were you enrolled at another institution during the term covered by this appeal? If yes, attach a certification of enrollment from the Registrar's Office of the institution you attended.

YES

NO

Are you requesting an exception due to extraordinary circumstances, such as illness or death in the family?

YES

NO

If yes, you MUST attach any supporting documentation, such as a letter from your doctor (with specific dates), obituary, or copy of a

death certificate and explain below.

Are you requesting an exception due to University error? If yes, MUST attach a letter from the department that made the error, and explain below.

YES

PLEASE PROVIDE ADDITIONAL INFORMATION ABOUT YOUR APPEAL IN THE SPACE BELOW (you may attach additional pages, if necessary): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

______________________________________________

_____________________

Student Signature

Date

The deadline to file an appeal is one year from the beginning of the semester affected. Complete appeals submitted by the 10th of the month will be

heard at the end of the month. Students will be notified by mail of the Committee's decision.

COMMITTEE: Review Date: _____________ Decision:

Approved

Denied

Form RC10-20-00

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